Minimally Invasive Surgery Pre Test Questions: 1. Carbon dioxide - PDF document

1/28/2011 Minimally Invasive Surgery • Pre Test Questions: 1. Carbon dioxide is used to create a Minimally Invasive Surgery pneumoperitoneum for laparoscopic surgery because it can be easily absorbed across the peritoneum? Aaron L. Cernero D.O. A. True General and Bariatric Surgery B. False Sherman, Texas 2.11.11 Minimally Invasive Surgery Minimally Invasive Surgery • Pre Test Questions: • Pre Test Questions: 2. Laparoscopy is contraindicated for pregnant 3.Which of the following diagnosis should be women in the third trimester? exclusively treated in the traditional open surgical technique? A. True B. False • A. Gangrenous Cholecystitis. • B. Acute appendicitis in a 24 week gravid female. • C. 65 y.o. male with a right colon cancer • D. 30 y.o. male with a reducible inguinal hernia • E. None of the above. Minimally Invasive Laparoscopic Minimally Invasive Laparoscopic Surgery (MILS) Surgery (MILS) • Objective: • History of MILS – Discuss History of MILS – Kelling 1901: Placed cystoscope into the – Discuss Physiology of Pneumoperitoneum abdomen for the first time – Discuss types of surgeries performed with minimal – Hopkins 1950: Described the rod lens which invasion allowed light to be transmitted without heat – Discuss Advantages of MILS – 1950s: Thin quartz fibers were discovered – Discuss Pre and Postoperative care leading to flexible fiberoptics – Discuss most common general laparoscopic – 1970s: Flexible endoscopy was developed surgeries – Discuss possible complications and there – 1980s-Present: Compact high resolution management. video cameras – Present and Future advancements in Laparoscopy 1

1/28/2011 Minimally Invasive Laparoscopic Minimally Invasive Laparoscopic Surgery (MILS) Surgery (MILS) • Physiology of MILS • Physiology of MILS – Pneumoperitoneum – Transabdominal incisions: • CO 2 • Laparoscopy allows us to visualize the entire – Gas specific effects: » Respiratory Acidosis caused by Carbonic Acid production abdominal compartment with minimal trauma » Bones are the largest reserve of buffers • Transection through the rectus muscles or midline » Respiratory system takes over when buffers are saturated can create severe pain and respiratory dysfunction – Pressure specific effects: » Decrease in venous return and cardiac output (pressure on – Endocrine balance: IVC) » Bradycardia is the most common arrhythmia • Laparoscopic surgery allows for a more rapid » Vagovagal response (treated with desufflation and equilibration of most stress mediated hormone atropine) levels. » Prevented by being normovolemic • Immune suppression is less after laparoscopy Minimally Invasive Laparoscopic Minimally Invasive Laparoscopic Surgery Surgery • Surgeries being performed with minimally invasive techniques: – Cholecystectomy – If a procedure is performed with the – Appendectomy – Hernia repair (incisional, inguinal, ventral) same basic principles, both open or – Colon resection (cancer and diverticulitis) laparoscopicaly, the chances are it – Bariatric surgery (Gastric Band, SG, RYGB) will be successful. – Endocrine (adrenalectomy and pancreatectomy) – Splenectomy – Foregut surgery Minimally Invasive Laparoscopic Minimally Invasive Laparoscopic Surgery Surgery • Advantages of MILS • Decreased Surgical Site Infections (SSI): – Decreased risk of surgical site infections – Annals of Surgery 2003 1 • 54,500 inpatient Cholecystectomies – Decrease length of stay • 554 SSI were reported mostly Gram + bacteria – Fewer complications • 69% were discovered in the hospital and 38% in – Less pain postop follow up – Cosmetic (Smaller scars) • Risk of SSI 0.62% in laparoscopy and 1.82% in the – Lower risk of incisional hernias open procedure. – Less adhesions 2

1/28/2011 Minimally Invasive Laparoscopic Minimally Invasive Laparoscopic Surgery Surgery • Advantages of Laparoscopy: • Preoperative Evaluation: – The Lancet 2002 2 – Most patients are candidates for laparoscopic • Randomized trial surgery • 219 patients with colon cancer were treated with either – Patients who have had prior abdominal Laparoscopic-assisted colectomy or open colectomy. • Laparoscopic group had a shorter hospital stay than the open surgeries pose some risk and have a higher group 5days:8days. conversion rate • Fewer complications 12:111 patients vs. 31:108 – All major surgical cases should have basic • Relative risk reduction for LAC vs. OC was 61% for tumor relapse; 52% for death and 62% for cancer related death. labs and studies prior to surgery • CBC, CMP, Chest X-ray and EKG Minimally Invasive Laparoscopic Minimally Invasive Laparoscopic Surgery Surgery • Preoperative Evaluation (special cases) • Preoperative Evaluation (special cases) – Pregnant patients: – Pregnant patients: • SAGES 2009 3 • SAGES 2009 3 – 1:500 pregnant women will undergo non-obstetrical – Laparoscopy can safely be performed during any surgery. trimester of pregnancy – Most common surgeries are appendicitis, cholecystitis – Laparoscopy reduces the risk of uterine irritability and intestinal obstruction – Slightly higher risk of DVT so TED and SCD placement – Radiation exposure and fetal age are the most important factors with cumulative ionized radiation dose of 5-10 with early ambulation is recommended. rads and weeks 10-17 as the most critical time. – Laparoscopy and pneumoperitoneum is safe – US and MRI without gadolinium are safe – CT scan usually gives 2-4 rads. Minimally Invasive Laparoscopic Minimally Invasive Laparoscopic Surgery Surgery • Preoperative Evaluation (special cases) • Laparoscopy for Cancer – Incisional hernias – Annals of Surgery 2009 4 • All patients should have CT scan to determine the • Retrospective study of 471 patients undergoing size, location and content of hernias resection for rectal cancer (238 Laparoscopy and 233 Open) • If the hernia is large, multiple or contains significant amount on intra-abdominal contents • Mortality 0.8% vs. 2.6%, Morbidity 22.7% vs. should consider open procedure and possible 20.2% and quality of surgery 92% vs. 90%. component separation. • Findings: Laparoscopic resection is as effective as open and there is similar long-term local control with improved cancer-free survival rate. 3

1/28/2011 Most Common Laparoscopic Minimally Invasive Laparoscopic Surgery Surgeries • New indications for Laparoscopic • Cholecystectomy: Sigmoidectomy – Most common major abdominal procedure in Western countries – 1882: Carl Langenbuch performed first case – 1987: Philippe Mouret (France) performed first laparoscopic cholecystectomy – Revolutionized laparoscopy in the US – Now the standard of care for gallbladder surgery Most Common Laparoscopic Most Common Laparoscopic Surgeries Surgeries • Cholecystectomy: • Cholecystectomy: – Indications: – Preoperative Testing: • Symptomatic Gallstones • CBC, Liver function test • Decreased Ejection Fraction and recreation of • US +/- HIDA scan symptoms by HIDA scan – Risk: – Contraindications: • Mortality rate is 0.1% • Uncontrolled coagulopathy • Possible complications • End-stage liver disease – Bile duct injury » 0.55% risk of major injury – Relative contraindications: » 0.3% risk of minor injury • COPD, CHF with EF< 20% » Total of 0.85% – Bowel injury Most Common Laparoscopic Most Common Laparoscopic Surgeries Surgeries • Cholecystectomy: • Cholecystectomy – Diagnosis of Bile Duct Injury • 25% are identified at time of injury • 50%+ will present within the first month • Rest present over the next months to years • Symptoms: – Pain, Fever, elevation in LFTs and jaundice – CT scan can identify bilomas or free fluid in the abdomen – HIDA scan can identify active leak – ERCP can be used to stent bile duct and relieve obstruction 4